New patients

New patient registration

Submit one request for yourself and up to five people in your household. Clinic staff will review it and contact you. Submitting this form does not guarantee acceptance as a patient.

Primary patient

The clinic will use this person as the main contact for the household request.

First name

Last name

Email address

Optional

Phone number

Date of birth

Health card

Health card number

Enter the 10-digit number without the version code.

Version code

The one or two letters beside the card number.

Home address

Street address

Address line 2

City

Province

Postal code

Doctor preference (optional)

Preferred doctor

Optional. Leave blank if you have no preference.

Household members (optional)

Only needed if a spouse, child or dependent is registering at the same time as you. If you are registering just yourself, skip this section and submit the form.

Household member 1

Relationship

First name

Last name

Date of birth

Health card number

Version code

Household member 2

Relationship

First name

Last name

Date of birth

Health card number

Version code

Household member 3

Relationship

First name

Last name

Date of birth

Health card number

Version code

Household member 4

Relationship

First name

Last name

Date of birth

Health card number

Version code

Household member 5

Relationship

First name

Last name

Date of birth

Health card number

Version code

Consent and additional information

Additional message

Optional. Avoid detailed medical information.

The clinic may contact me about this registration request.

I consent to communication if this request is placed on a waitlist.

Clinic policies

The clinic does not prescribe narcotics or controlled substances.

Aggressive, threatening, abusive, disruptive or otherwise unacceptable conduct toward clinic staff or physicians may result in termination of the patient-doctor relationship.

Privacy information

Review the privacy information (opens in a new tab) before submitting. The clinic-approved privacy notice is clearly marked there as a launch requirement.

I have reviewed the linked privacy information before submitting.